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Care and Management of the HIV+ Youth

Care and Management of the HIV+ Youth. Ronald Wilcox MD FAAP. Care and Management of the HIV+ Youth. Ronald Wilcox MD FAAP AKA Man with Many Hats. What is your profession?. Student / Resident / Fellow Primary Care Provider in Practice Specialty Provider in Practice Nursing Public Health

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Care and Management of the HIV+ Youth

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  1. Care and Management of the HIV+ Youth Ronald Wilcox MD FAAP

  2. Care and Management of the HIV+ Youth Ronald Wilcox MD FAAP AKA Man with Many Hats

  3. What is your profession? • Student / Resident / Fellow • Primary Care Provider in Practice • Specialty Provider in Practice • Nursing • Public Health • Pharmacist • Other

  4. HIV in Youth • Is very rare • Occurs only in MSM • Is found proportionately to racial make-up of US • Is a growing epidemic

  5. What is your level of experience of dealing with HIV+ adolescents? • Non-existent • Minimal • Moderate • High • Expert • Don’t believe there is any HIV in teens

  6. Case 1 • An 18 year old boy recently aged out of foster care. • He received transitional services and had a job in a fast food restaurant when he left his foster home. • He quickly lost that job and is now homeless. • He’s living on the streets and makes money panhandling. • He also sometimes sells sex to other men but tells you he’s not sexually attracted to men and just needs money. • You do an HIV antibody test and it’s negative.

  7. Which of the following groups is the largest in terms of adolescents 13-24 years of age diagnosed with HIV infection: • White males • White females • African-American males • African-American females • Hispanic males • Hispanic females

  8. The age group with the highest rate of new HIV infections this year in the US is estimated to be: • 1-13 years old • 13-24 years old • 25-40 years old • 40-55 years old • Over 55 years of age

  9. LA Statistics (09/30/12)HIV/ AIDS Diagnosis in 2011 by Age <1 % 25%

  10. All of the following are examples of factors of increased risk for HIV for adolescents EXCEPT: • Feelings of invulnerability • Size of the ectropion • Peer pressure • Consistency of condom use • Rate of other STDs • All of the above

  11. HIV Risk in Youth Access to care Domestic or sexual abuse Mental health issues Substance abuse issues Commercial sexual behavior Social networking and sexting • Exploration of sexuality • Lack of sense of risk and feeling of invincibility • Lack of condom use • Incidence of other STDs • Social situations – ie homelessness • Transformation zone

  12. RISK FACTORS • High Rates of STDs • Biologically More Susceptible • Columnar tissue thin and friable • Earlier menarche • History of Sexual Abuse • Types of sexual activity

  13. The transformation zone • Is a clinic which caters to transgendered youth • Is larger in older women than younger women • Is area of the cervix which changes from squamous to columnar epithelium • Is the area where the vaginal tissue has the highest density of lymphocytes

  14. Cervical Epithelium

  15. Sexual Activity • J Peds & Adol GYN, Volume 20, Issue 5, Oct 2007, Pp 299-304 • Reproductive health histories from 350 sexually-experienced adolescent females aged 12-18 participating in a 5-year STI acquisition study at an urban health center

  16. Sexual Activity • 41% teens had sexual relations with casual partners, 86% with main partners • Anal intercourse – 16% with main partners and 12% of those with casual partners • Condom use more with casual than main • Vaginal – 61% versus 32.4% • Anal – 47.1% vs 21.3% • Casual relationship – more likely to use anal intercourse for contraception

  17. Anal Intercourse in Young Adults • Gorbach PM et al. Anal intercourse among young heterosexuals in three sexually transmitted disease clinics in the United States. Sex TransmDis 2009 Mar 4; e-pub ahead of press. • 2001-2004: Interviewed 1084 heterosexual 18-26 y/o patients in Seattle, New Orleans, and St. Louis presenting to an STD clinic • 37% had anal intercourse at some point • 28.9% had anal intercourse with at least 1 of last 3 partners • 19% had anal intercourse with their last partner • Women reported less condom use with last AI than men (26% versus 45%, p<0.001) • Risk for AI for women: meeting partner same day, having over 3 partners in lifetime, and having sex for money

  18. Risky behavior • 2009 • 46% of high school students had had intercourse • 34% in past three months • 39% did not use a condom the last time • 77% did not use other contraception • 14% had 4 or more partners in lifetime • 8300 cases of HIV in 13-24 year olds • Nearly half of all new STDs in 15-24 year olds • > 400,000 teen girls gave birth www.cdc.gov fact sheets on Sexual Behaviors of Adolescents

  19. Patients are at highest risk of potential exposure to HIV at which developmental stage: • Prepubertal • Early adolescence • Middle adolescence • Late adolescence • Middle age

  20. Middle Adolescenceages 14-16 • Often the greatest experimental, risk-taking time • Drinking, drugs, smoking, and sexual experimentation highest interest between 12 and 16 years • This is when first intercourse, first drink, or first pregnancy frequently occur

  21. Middle Adolescence • Little concept of cause and effect • Omnipotence and invulnerability are the rule • Unpredictable surges in sexual drive • Sexuality is often the MAJOR preoccupation of the middle adolescent

  22. RISK FACTORS CONTINUED • Minority Youth • Serial Monogamy • Gay and bisexual males • Homeless or runaway youth

  23. Minority MSM • African-American male youth • Frequently don’t identify as “gay” or “bisexual” • Prevalence up to 33% • 4% - 8% chance of acquisition per year  40-60% chance infected by age 40

  24. CDC Recommendations for HIV Screening and Testing

  25. The CDC recommends routine HIV screening for what age range • 1 year to 13 years • 13 years to 23 years • 13 years to 50 years • 13 years to 64 years • 24 years to 99 years

  26. Risk assessment • HIV Testing should be offered routinely from 13-64 years of age • Consider yearly testing in 13-24 year old and others at high risk • Testing based ONLY on reported risk discouraged • 25 years of age and older – yearly risk assessment and consider testing

  27. Assessment in Youth • Assure confidentiality • Refrain from speaking with parents privately without expressed permission from youth • Assure parents do not stand outside room • Place siblings in different rooms • Obtain patient’s cell phone at each visit and assure patient that results will be given directly to him/her • Ask nursing staff to knock before entering and refrain from talking with parents without patient’s express consent Nass MT, Pasternak RH. HIV Clinician Spring 2012; 24(2): 3-6

  28. Assessment in youth • Repeat the same questions to each patient • Perform risk assessments at preventive and acute care visits • Don’t assume patient understands the ? • Consider rephrasing it • Ask patient what they mean by “sex” and ask about specific behaviors • Lead with questions that minimize vulnerability • Use gender neutral language • Avoid using personal norms as standards Nass MT, Pasternak RH. HIV Clinician Spring 2012; 24(2): 3-6

  29. Testing and TreatmentConsiderations in Youth

  30. Case 2 • A 15 year old young woman decides to become sexually active with her 24 year old boyfriend. They do not use condoms because he wants her to “prove her love” and tells her she is his only girlfriend. • She later finds out that he also has a boyfriend so she goes to her school based clinic and asks for a test for STDs. Her rapid HIV test is positive.

  31. HIV Testing • Consent legal age depends on state law • “Opt-in” versus “Opt-out” • When possible, use rapid testing for youth

  32. Repeat testing • Patients at high risk for HIV based on risk assessment, offered yearly • Adolescents are classified as “high risk” • MSM • IVDU • Known HIV+ partners

  33. Requested Testing • Usually within first 24 hours of a high risk behavior • Often requested when they had a previous positive test to confirm.

  34. ACTS in terms of HIV counseling and testing refers to: • Advise, confer, teach, simulate • Assessment, counseling, testing, support • Advertise, coerce, train, supervise

  35. ACTS • Assessment: • Education • Identification of risk factors • Provide recommendations for testing, prevention, and referral

  36. ACTS • Assessment • Counseling • Clarifies meaning of positive and negative test • Patient readiness and social support network are assessed • Consent is obtained

  37. ACTS • Assessment • Counseling • Testing • Rapid testing preferred except when hospitalized • Must confirm positive results with Western Blot

  38. ACTS • Assessment • Counseling • Testing • Support • Negative result – stress importance of retest in 3 months and ways to decrease risk • Positive result – offer support and referral for treatment and prevention. Discuss partner notification.

  39. Factors for Testing: Connect 2 Protect (ATN) • Individual factors • Less likely if • < 18 y/o • Still in school • More likely if • African-American (2 x) • G/L/B activity (3x) • Had 3 or more sex partners in 3 months • Ever had an STI • Used condoms “half the time” or less • Using substances during the sexual encounter • Had a known HIV+ partner Straub DM, Arrington-Sanders R, Harris DR et al. Correlates of HIV Testing History Among Urban Youth Recruited Through Venue-Based Testing in 15 US Cities. Sexually Transmitted Diseases 2011 Aug; 38(8): 691-6.

  40. Factors for TestingConnect 2 Protect (ATN) (Straub) • Partner Factors • Less likely if • > or = 1 episode when a partner made them have sex without a condom • Had a partner with unknown status compared to those with HIV negative partners (p<0.001) • More likely if • Partner who used hard drugs • Partner who had relationships outside the primary (p<0.001)

  41. HIV Testing in Adolescents • 16,410 students who participated in 2009 national Youth Risk Behavior Survey • 7,591 reported ever having intercourse • 22.6% had ever been HIV tested • Used IV drugs at least once (280) - 41% ever HIV tested • Forced to have sex (1055) - 36% ever tested for HIV • Did not use condom at last intercourse (4797) – 28.7% tested • Had 4 or more partners (2292) – 34.7% tested Balaji AB, Eaton DK, Voetsch AC et al. Arch PediatrAdolesc Med 2012 Jan (epub) with editorial by D’Angelo L.

  42. Diagnosis Reactions • Denial • Anger • Unwillingness to disclose • Depression • Stoicism

  43. 821-4611

  44. Health Promotion After Diagnosis • Sexual health education • Disclosure education • Importance of adherence to medical care and medications • Treatment as prevention • Harm reduction counseling regarding illicit drug use • Support of youth as they continue to mature • Transition of care when ages to adulthood

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